- Email: [email protected]
International Federation for Emergency Medicine Model curriculum for medical student education in emergency medicine
African Journal of Emergency Medicine (2011) 1, 139–144
African Federation for Emergency Medicine
African Journal of Emergency Medicine www.afjem.com www.sciencedirect.com
International Federation for Emergency Medicine Model curriculum for medical student education in emergency medicine Fe´de´ration Internationale de Me´decine d’Urgence Programme modele pour la formation des etudiants en me´decine en matiere de me´decine d’urgence Cherri Hobgood a,*,1, Venkataraman Anantharaman b,1, Glen Bandiera c,1, Peter Cameron d,1, Pinchas Halperin e,1, James Holliman f,1, Nicholas Jouriles Darren Kilroy h,1, Terrence Mulligan i,1, Andrew Singer j,1 a
Emergency Medicine, Indiana University School of Medicine, IN, USA Singapore General Hospital, Singapore, Singapore c Michael’s Hospital, University of Toronto, Toronto, ON, Canada d The Alfred Hospital Emergency and Trauma Centre, Monash University, Melbourne, Australia e Tel Aviv Medical Center, Tel Aviv, Israel f Uniformed Services University of the Health Sciences, Bethesda, MD, USA g Akron General Medical Center, Akron, OH, USA h College of Emergency Medicine, London, United Kingdom i Erasmus University School of Medicine, Rotterdam, The Netherlands j Canberra Hospital, Woden, Australia b
Available online 14 September 2011 * Corresponding author. E-mail address: [email protected] (C. Hobgood). 1 For the International Federation for Emergency Medicine. 2211-419X ª 2011 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of African Federation for Emergency Medicine. doi:10.1016/j.afjem.2011.08.010
Production and hosting by Elsevier
g,1
,
140
KEYWORDS Curriculum; International emergency medicine; Medical education; Medical students
C. Hobgood et al.
Abstract There is a critical and growing need for emergency physicians and emergency medicine resources worldwide. To meet this need, physicians must be trained to deliver time-sensitive interventions and life-saving emergency care. Currently, there is no internationally recognized, standard curriculum that defines the basic minimum standards for emergency medicine education. To address this lack, the International Federation for Emergency Medicine (IFEM) convened a committee of international physicians, health professionals and other experts in emergency medicine and international emergency medicine development, to outline a curriculum for foundation training of medical students in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed with a focus on the basic minimum emergency medicine educational content that any medical school should be delivering to its students during their undergraduate years of training. It is designed, not to be prescriptive, but to assist educators and emergency medicine leadership in advancing physician education in basic emergency medicine content. The content would be relevant, not just for communities with mature emergency medicine systems, but also for developing nations or for nations seeking to expand emergency medicine within current educational structures. We anticipate that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational milieu, the resources available, and the goals of the institutions’ educational leadership. ª 2011 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved.
Il existe un besoin crucial et croissant en me´decins d’urgence et en ressources de me´decine d’urgence dans le monde. Pour y re´pondre, les me´decins doivent eˆtre forme´s afin de pouvoir accomplir des interventions pre´sentant un caracte`re d’urgence et des soins d’urgence vitaux. Actuellement, il n’existe aucun programme standard reconnu au niveau international de´finissant les crite`res minimum de base pour l’enseignement en me´decine d’urgence. Afin de palier cette lacune, la Fe´de´ration Internationale de Me´decine d’Urgence (IFEM) a convoque´ un comite´ de me´decins internationaux, de professionnels de la sante´ et autres experts en me´decine d’urgence et de´veloppement international de la me´decine d’urgence afin de de´finir un programme de formation de base des e´tudiants en me´decine d’urgence. Ce programme constitue le consensus des recommandations formule´es par ce comite´. Le programme est conc¸u de manie`re a` traiter essentiellement du contenu e´ducatif en me´decine d’urgence minimum de base que toute e´cole de me´decine doit fournir a` ses e´tudiants au cours de leurs anne´es de formation the´orique. Il n’est pas conc¸u a` des fins normatives mais pour aider les formateurs et les organes de tutelle de la me´decine d’urgence a` faire progresser la formation des me´decins en matie`re de me´decine d’urgence de base. Le contenu de ce programme est non seulement pertinent pour les communaute´s disposant de syste`mes de me´decine d’urgence de´veloppe´s, mais e´galement pour les pays en voie de de´veloppement ou les pays cherchant a` de´velopper la me´decine d’urgence au sein des structures d’enseignement actuelles. Nous pre´voyons une importante variabilite´ quant a` la fac¸on dont ce programme sera mis en œuvre et enseigne´, refle´tant le milieu e´ducatif en place, les ressources disponibles et les objectifs du leadership e´ducatif des institutions. ª 2011 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved.
Executive summary Vision: To create an international model curriculum for medical student foundation training in emergency medicine. Rationale: There is critical, overwhelming and growing need for emergency physicians and other administrative, professional, clinical and academic emergency medicine resources worldwide. Currently, there exist a small number of national curricula for emergency medicine, but there is no standard, widely recognized international curriculum for medical students.
Demand: Currently worldwide, there are roughly 50+ countries involved in the processes of emergency medicine development. Internationally, a consensus is building regarding the demand for an international minimum basic standard for emergency medicine curriculum content. Goal: To establish, develop and maintain an international curriculum for medical student foundation training in emergency medicine. The curriculum should be compiled by an international consortium of physicians, health professionals and other experts in emergency medicine and international emergency medicine development. Further it should be
141 approved, amended and maintained by an international collection of such experts. Endpoint: To further train and educate physicians, medical professionals and other experts in emergency medicine, in order to provide the best quality emergency care in the multiple and growing number of nations where it is currently practiced, and to further establish emergency medicine as a medical profession worldwide. Mission statement The International Federation for Emergency Medicine believes that: Society has a right to expect that at the completion of their undergraduate medical school training all physicians possess the basic knowledge of emergency care and the skills to manage common acute problems. Emergency medicine is a core medical discipline and should be a required portion of the curriculum for every medical school, and every medical student, in the world. Every physician, and graduating medical student, should be able to provide care in an emergency situation without any faults or lack of confidence and should be independent of the site of the emergency. Every physician, and medical student, should be able to manage clinical decision-making under pressure of time when it is essential to save lives. Competence in basic emergency medicine should be an outcome measure for all medical students and represent a criteria required for conference of the degree.
Introduction This curriculum establishes an international consensus on the core content of undergraduate level emergency medicine training with the goal of elevating the quality of acute care worldwide through an expansion of basic emergency medicine education. This curriculum further reflects the importance of emergency medicine as a medical profession worldwide. The document is organized sequentially, as a framework rather than a comprehensive plan. Educators using this curriculum should make use of the framework to develop educational programs that are contextualized and specifically meet local educational requirements. This model allows easy adaptation of any of the features and provides an example of an expanded 4-year curriculum for a single learning objective. Professional development The clinical settings and environmental context for medical education varies widely throughout the world. To attain minimum basic competency in emergency medicine core learning objectives, medical students must be given a variety of opportunities for professional development. These opportunities should be longitudinal in nature, begin early in the pre-clinical years, and extend into clinical contexts that allow focus on acute and emergency conditions. The following basic guidelines should structure the educational process of achieving core competencies in minimum emergency medicine knowledge and skills.
During undergraduate and early training every medical student should: Acquire a fundamental knowledge of basic sciences as applied to emergency medicine and have the ability to assess and immediately treat common emergencies. Develop existing clinical examination skills and apply them in clinical practice to develop differential diagnoses and provisional management plans for acute medical conditions and undifferentiated patients. Acquire expertise in a range of commonly used emergency procedural skills, including basic life support. Perform allocated tasks, learn to process serially so as to optimally manage time within the shift, and meet clinical deadlines. Teach informally in the clinical setting and in specified circumstances in a more formal setting. Develop an understanding and basic awareness of clinical management issues when applied to acute care situations. Select and perform simple audit projects and understand the audit cycle to monitor care delivery and improve care quality. Understand the principles of critical appraisal and research methodology and apply these to acute care situations. Demonstrate the capacity to work in multi-professional teams. Learn to recognize his or her own limitations in the provision of emergency care.
Educational outcomes – Learning objectives These learning objectives are designed to allow easy modification to the local needs and are written so that objective measures of performance and competency can be designed to measure attainment of the learning objective. The student should
1. Acquire basic life support skills, including the diagnosis and treatment of shock and the related basic procedural skills; and demonstrate the basic application of these principles in real or simulated patient care scenarios. 2. Demonstrate the capacity to differentiate and treat common acute problems. 3. Provide a comprehensive assessment of the undifferentiated patient. 4. Demonstrate proficiency in basic life support skills and cardiopulmonary resuscitation. 5. Recognize and initiate first aid for airway obstruction. 6. Recognize and be prepared to intervene for all causes of shock in any age group. 7. Be able to provide rapid stabilization with intravenous access and fluid/blood administration. 8. Understand the principles of cerebral resuscitation in brain illness and injury. 9. Demonstrate proficiency in the use of an automatic external defibrillator (AED). 10. Understand the principles of wound care. 11. Demonstrate basic wound care techniques. 12. Understand the principles of trauma management.
142 13. Demonstrate basic trauma management skills, such as initial assessment using the ABC approach and full spine immobilization. 14. Demonstrate mastery of basic procedural skills, such as airway management and venous access. 15. Recognize life-threatening illness or injury, and apply basic principles of stabilization to the early management of these entities. 16. Demonstrate the capacity to prioritize attention to those patients with more urgent conditions. 17. Describe the importance of the ED as a key link between the general population and the health care system. 18. Understand the role of the situations that are unique to emergency medicine: acute critical illness, intoxicated patients, media, out-of-hospital personnel, death notification for sudden unexpected death, disaster, language barriers, environmental illness/injury, injury prevention, assessment of complex and undifferentiated patients, ability to synthesize multiple and often incomplete sources of information to develop a management plan.
C. Hobgood et al. Manual, Dallas, TX, USA or equivalent manuals from the local community]. Performance indicators
1. 2. 3. 4.
Obtain basic cardiac life support (BCLS) certification. Demonstrate chin lift. Demonstrate bag–valve mask ventilation. Demonstrate the ability to clear an obstructed airway.
Curriculum year 2 Readings – Pathophysiology of respiratory failure Curriculum year 3 and/or 4 Readings – Introduction to anesthesia, Introduction to airway management. Performance indicators
Unique content areas for Emergency Medicine in Foundation Training Undifferentiated patient presentation. Time constrained decision making. Environmental illness and injury. Pre-hospital care. Transition point between community and hospital. Focused history and exam. Prioritized differential diagnoses. Lead role areas for Emergency Medicine in Foundation Training Acute illness. Acute injury. Disaster management. Death notification. Injury prevention. Medical decision making. Resource utilization. Toxicology.
1. 2. 3. 4. 5.
Demonstrate endotracheal intubation. List indications for intubation. List contraindications for intubation. Describe medications used for rapid sequence intubation. Describe the physiology of artificial ventilation.
Outcome measures At time of graduation, student will demonstrate the ability to: n manage an obstructed airway n manage a basic airway, and n perform an endotracheal intubation. This will be assessed by simulation on a mannequin or using direct observation of student skills by trained faculty during clinical situations.
Example curriculum format
Undergraduate Emergency Medicine Curriculum Content
To assist educators in crafting a curriculum that fits local needs, we have provided an example of a 4 years plan for a single learning objective. Educators may use this as a guide to construct individual-, national-, and institution-specific models for content delivery. This method is not intended to be prescriptive, but to provide a simple model for tailoring content to the unique educational models that exist throughout the world.
Skills curriculum
Learning objective # 5 Recognize and initiate first aid for airway obstruction. Curriculum year 1 Readings – Basic life support manuals, basic first aid manuals [e.g., American Heart Association Advanced Life Support
1. Clinical care skills 1.1. History and examination 1.2. Documentation 1.3. Decision making 1.4. Time management 1.5. Safe prescribing 1.6. Continuity of care 1.7. Therapeutic interventions 2. Communication skills 2.1. With colleagues 2.2. With patients and caregivers 2.3. Breaking bad news 2.4. Working with a team
143 3. Maintaining good medical practice – life long learning 3.1. Audit and clinical outcomes 3.2. Critical appraisal 3.3. Information management 4. Professional behaviour and probity – professional attributes 4.1. Career and professional development 5. Ethics and Legal 5.1. DNAR and advanced directives 5.2. The competent adult 5.3. Informed consent 6. Education – developing learning for others 6.1. Basic educational information delivery 6.2. Assessment and appraisal 6.3. Feedback 7. Maintaining good clinical care - risk management 7.1. Medico-legal issues 7.2. Confidentiality
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Speciality specific curriculum 16. 1. Generic Objectives for Resuscitation 1.1. Resuscitation – Airway 1.2. Cardiac Arrest/Peri-arrest 1.3. Shock – all varities (varieties?) 1.4. Coma 2. Anaesthetics and Pain Relief - Pain Management 2.1. Local anesthetic techniques 2.2. Safe conscious sedation 3. Wound Management 3.1. Basic wound debridement and closure 3.2. Identification and treatment of infected wounds 4. Generic Objectives for Trauma 4.1. Major Trauma 4.2. Head Injury 4.3. Chest Trauma 4.4. Abdominal Trauma 4.5. Spinal Injury 4.6. Maxillo-facial Trauma 4.7. Burns 4.8. Orthopedic Trauma 5. Generic Objectives for Musculoskeletal Conditions 5.1. Upper limb disorders 5.2. Lower limb and pelvis disorders 5.3. Spine and spinal cord conditions 6. Vascular Emergencies 6.1. Arterial limb threat 6.2. Venous – Deep Venous Thrombosis (DVT) 7. Abdominal Conditions 7.1. Undifferentiated abdominal pain 7.2. Haematemesis/malena 7.3. Anal pain and rectal bleeding 7.4. Diverticulitis 7.5. Abdominal aortic aneurysm 8. Urology 8.1. Acute urinary retention or bladder obstruction 8.2. Nephrolithiasis and colic 9. Sexually Transmitted Diseases 9.1. Identification and initial treatment for endemic diseases 10. Eye Problems 10.1. Acute conjunctivitis - bacterial and viral
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10.2. Acute vision loss 10.3. Acute eye trauma including globe rupture Ear, nose and throat (ENT) Conditions 11.1. Epistaxis 11.2. Infections of the head and neck Dental Emergencies 12.1. Dental abscess 12.2. Dental fracture Gynecology 13.1. Pelvic pain 13.2. Dysfunctional uterine bleeding Obstetrics 14.1. Ectopic pregnancy 14.1. Uncomplicated emergency vaginal delivery Cardiology 15.1. Basic electrocardiographic analysis 15.2. Recognition and initial treatment of acute myocardial infarction 15.3. Recognition and initial treatment of life threatening arrhythmia Respiratory Medicine 16.1. Airway obstruction 16.2. Respiratory failure 16.3. Asthma and restrictive airway disease 16.4. Acute pneumothorax 16.5. Pulmonary embolism Neurological Emergencies 17.1. Acute stroke 17.2. Spinal cord lesions 17.3. Peripheral neuropathies 17.4. Acute mental status change 17.5. Migraine 17.6. Meningitis 17.7. Vertigo Hepatic Disorders 18.1. Acute hepatitis 18.2. Liver failure 18.3. Acute cholecystitis and cholangitis Toxicology 19.1. Treatment of acute ingestions 19.2. Identification of basic toxidromes Acid Base and Ventilatory Disorders 20.1. Identification of acid base disorders 20.2. Initial management of the mechanically ventilated patient Fluid and Electrolytes 21.1. Basic principles of fluid administration 21.2. Dehydration 21.3. Hyperkalemia 21.4. Hyponatremia Renal Disease 22.1. Acute renal failure Diabetes and Endocrinology 23.1. Disorders of glucose metabolism 23.2. Thyroid disorders Haematology 24.1. Anaemia 24.2. Disorders of red cell function 24.3. Disorders of clotting Infectious Diseases and Sepsis 25.1. Endemic infectious diseases 25.2. Sepsis
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C. Hobgood et al. 25.3. Common infectious diseases or conditions (e.g. pneumonia) 25.4. Cellulitis and gangrene Dermatology 26.1. Blistering and exfoliative diseases 26.2. Differential diagnosis of rash 26.3. Parasitic conditions and infestations Rheumatology and Immunology 27.1. Crystal arthropathy 27.2. Arthritis 27.3. Immune disorders 27.4. Anaphylaxis Child Protection and Children in Special Circumstances 28.1. Child abuse signs and symptoms 28.2. Legal rights of parents to refuse care Neonatology 29.1. Neonatal resuscitation 29.2. Hyperbilirubinemia 29.3. Disorders of feeding 29.4. Neonatal fever Environmental Emergencies 30.1. Hyperthermia 30.2. Hypothermia and frostbite 30.3. Envenomation and environmental toxin exposure Oncology 31.1. Acute leukaemia 31.2. Neutropenia and neutropenic fever 31.3. Solid tumors 31.4. Complications of chemotherapeutic agents Pediatrics 32.1. Basic management of pediatric airway 32.2. Basic pediatric resuscitation 32.3. Common infectious diseases of childhood 32.4. Fever in the first 6 months of life 32.5. Common injury patterns for normal children Psychiatry 33.1. Acute psychosis 33.2. Mood disorders 33.3. Personality disorders 33.4. Acute suicidal and homicidal ideation 33.5. Substance abuse Major Incident Management 34.1. Concepts and application of triage
34.2. Field to hospital communication and chain of command 35. Legal Aspects of Emergency Medicine 35.1. Refusal of care 35.2. Informed consent 35.3. Malpractice 36. Research 36.1. Formulating a research question 36.2. Review of the medical literature 36.3. Basic research design 36.4. Basic preparation of manuscripts and written publications 37. Management 37.1. Leading teams and giving orders 37.2. Basic concepts of debriefing and giving feedback 37.3. Time flow management Further reading 1. The Foundation Programme Committee of the Academy of Medical Royal Colleges. Curriculum for the Foundation Years in Post Graduate Education and Training. Academy of Medical Royal Colleges. Available at:; 2009 [accessed 22.02.09]. 2. Liaison Committee on Medical Education. LCME Accreditation Standards (with annotations). Liaison Committee on Medical Education June 2008. Available at: ; 2009 [accessed 22.02.09]. 3. Frank JR. The CanMEDS 2005 Physician Competency Framework. Better Standard, Better Physicians, Better Care. The Royal College of Physicians and Surgeons of Canada; 20009 [accessed 1.03.09]. 4. Manthey DE, Coates WC, Ander DS, et al.. Report of the Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide. Ann Emerg Med 2006;47(3):e1–7. 5. Hockberger RS, Binder LS, Chisholm CD, et al.. The model of the clinical practice of emergency medicine: a 2-year update. Ann Emerg Med 2005;45(6):659–74. 6. Chapman DM, Hayden S, Sanders AB, et al.. Integrating the Accreditation Council for Graduate Medical Education Core competencies into the model of the clinical practice of emergency medicine. Ann Emerg Med 2004;43(6):756–69.
African Federation for Emergency Medicine
African Journal of Emergency Medicine www.afjem.com www.sciencedirect.com
International Federation for Emergency Medicine Model curriculum for medical student education in emergency medicine Fe´de´ration Internationale de Me´decine d’Urgence Programme modele pour la formation des etudiants en me´decine en matiere de me´decine d’urgence Cherri Hobgood a,*,1, Venkataraman Anantharaman b,1, Glen Bandiera c,1, Peter Cameron d,1, Pinchas Halperin e,1, James Holliman f,1, Nicholas Jouriles Darren Kilroy h,1, Terrence Mulligan i,1, Andrew Singer j,1 a
Emergency Medicine, Indiana University School of Medicine, IN, USA Singapore General Hospital, Singapore, Singapore c Michael’s Hospital, University of Toronto, Toronto, ON, Canada d The Alfred Hospital Emergency and Trauma Centre, Monash University, Melbourne, Australia e Tel Aviv Medical Center, Tel Aviv, Israel f Uniformed Services University of the Health Sciences, Bethesda, MD, USA g Akron General Medical Center, Akron, OH, USA h College of Emergency Medicine, London, United Kingdom i Erasmus University School of Medicine, Rotterdam, The Netherlands j Canberra Hospital, Woden, Australia b
Available online 14 September 2011 * Corresponding author. E-mail address: [email protected] (C. Hobgood). 1 For the International Federation for Emergency Medicine. 2211-419X ª 2011 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of African Federation for Emergency Medicine. doi:10.1016/j.afjem.2011.08.010
Production and hosting by Elsevier
g,1
,
140
KEYWORDS Curriculum; International emergency medicine; Medical education; Medical students
C. Hobgood et al.
Abstract There is a critical and growing need for emergency physicians and emergency medicine resources worldwide. To meet this need, physicians must be trained to deliver time-sensitive interventions and life-saving emergency care. Currently, there is no internationally recognized, standard curriculum that defines the basic minimum standards for emergency medicine education. To address this lack, the International Federation for Emergency Medicine (IFEM) convened a committee of international physicians, health professionals and other experts in emergency medicine and international emergency medicine development, to outline a curriculum for foundation training of medical students in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed with a focus on the basic minimum emergency medicine educational content that any medical school should be delivering to its students during their undergraduate years of training. It is designed, not to be prescriptive, but to assist educators and emergency medicine leadership in advancing physician education in basic emergency medicine content. The content would be relevant, not just for communities with mature emergency medicine systems, but also for developing nations or for nations seeking to expand emergency medicine within current educational structures. We anticipate that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational milieu, the resources available, and the goals of the institutions’ educational leadership. ª 2011 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved.
Il existe un besoin crucial et croissant en me´decins d’urgence et en ressources de me´decine d’urgence dans le monde. Pour y re´pondre, les me´decins doivent eˆtre forme´s afin de pouvoir accomplir des interventions pre´sentant un caracte`re d’urgence et des soins d’urgence vitaux. Actuellement, il n’existe aucun programme standard reconnu au niveau international de´finissant les crite`res minimum de base pour l’enseignement en me´decine d’urgence. Afin de palier cette lacune, la Fe´de´ration Internationale de Me´decine d’Urgence (IFEM) a convoque´ un comite´ de me´decins internationaux, de professionnels de la sante´ et autres experts en me´decine d’urgence et de´veloppement international de la me´decine d’urgence afin de de´finir un programme de formation de base des e´tudiants en me´decine d’urgence. Ce programme constitue le consensus des recommandations formule´es par ce comite´. Le programme est conc¸u de manie`re a` traiter essentiellement du contenu e´ducatif en me´decine d’urgence minimum de base que toute e´cole de me´decine doit fournir a` ses e´tudiants au cours de leurs anne´es de formation the´orique. Il n’est pas conc¸u a` des fins normatives mais pour aider les formateurs et les organes de tutelle de la me´decine d’urgence a` faire progresser la formation des me´decins en matie`re de me´decine d’urgence de base. Le contenu de ce programme est non seulement pertinent pour les communaute´s disposant de syste`mes de me´decine d’urgence de´veloppe´s, mais e´galement pour les pays en voie de de´veloppement ou les pays cherchant a` de´velopper la me´decine d’urgence au sein des structures d’enseignement actuelles. Nous pre´voyons une importante variabilite´ quant a` la fac¸on dont ce programme sera mis en œuvre et enseigne´, refle´tant le milieu e´ducatif en place, les ressources disponibles et les objectifs du leadership e´ducatif des institutions. ª 2011 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved.
Executive summary Vision: To create an international model curriculum for medical student foundation training in emergency medicine. Rationale: There is critical, overwhelming and growing need for emergency physicians and other administrative, professional, clinical and academic emergency medicine resources worldwide. Currently, there exist a small number of national curricula for emergency medicine, but there is no standard, widely recognized international curriculum for medical students.
Demand: Currently worldwide, there are roughly 50+ countries involved in the processes of emergency medicine development. Internationally, a consensus is building regarding the demand for an international minimum basic standard for emergency medicine curriculum content. Goal: To establish, develop and maintain an international curriculum for medical student foundation training in emergency medicine. The curriculum should be compiled by an international consortium of physicians, health professionals and other experts in emergency medicine and international emergency medicine development. Further it should be
141 approved, amended and maintained by an international collection of such experts. Endpoint: To further train and educate physicians, medical professionals and other experts in emergency medicine, in order to provide the best quality emergency care in the multiple and growing number of nations where it is currently practiced, and to further establish emergency medicine as a medical profession worldwide. Mission statement The International Federation for Emergency Medicine believes that: Society has a right to expect that at the completion of their undergraduate medical school training all physicians possess the basic knowledge of emergency care and the skills to manage common acute problems. Emergency medicine is a core medical discipline and should be a required portion of the curriculum for every medical school, and every medical student, in the world. Every physician, and graduating medical student, should be able to provide care in an emergency situation without any faults or lack of confidence and should be independent of the site of the emergency. Every physician, and medical student, should be able to manage clinical decision-making under pressure of time when it is essential to save lives. Competence in basic emergency medicine should be an outcome measure for all medical students and represent a criteria required for conference of the degree.
Introduction This curriculum establishes an international consensus on the core content of undergraduate level emergency medicine training with the goal of elevating the quality of acute care worldwide through an expansion of basic emergency medicine education. This curriculum further reflects the importance of emergency medicine as a medical profession worldwide. The document is organized sequentially, as a framework rather than a comprehensive plan. Educators using this curriculum should make use of the framework to develop educational programs that are contextualized and specifically meet local educational requirements. This model allows easy adaptation of any of the features and provides an example of an expanded 4-year curriculum for a single learning objective. Professional development The clinical settings and environmental context for medical education varies widely throughout the world. To attain minimum basic competency in emergency medicine core learning objectives, medical students must be given a variety of opportunities for professional development. These opportunities should be longitudinal in nature, begin early in the pre-clinical years, and extend into clinical contexts that allow focus on acute and emergency conditions. The following basic guidelines should structure the educational process of achieving core competencies in minimum emergency medicine knowledge and skills.
During undergraduate and early training every medical student should: Acquire a fundamental knowledge of basic sciences as applied to emergency medicine and have the ability to assess and immediately treat common emergencies. Develop existing clinical examination skills and apply them in clinical practice to develop differential diagnoses and provisional management plans for acute medical conditions and undifferentiated patients. Acquire expertise in a range of commonly used emergency procedural skills, including basic life support. Perform allocated tasks, learn to process serially so as to optimally manage time within the shift, and meet clinical deadlines. Teach informally in the clinical setting and in specified circumstances in a more formal setting. Develop an understanding and basic awareness of clinical management issues when applied to acute care situations. Select and perform simple audit projects and understand the audit cycle to monitor care delivery and improve care quality. Understand the principles of critical appraisal and research methodology and apply these to acute care situations. Demonstrate the capacity to work in multi-professional teams. Learn to recognize his or her own limitations in the provision of emergency care.
Educational outcomes – Learning objectives These learning objectives are designed to allow easy modification to the local needs and are written so that objective measures of performance and competency can be designed to measure attainment of the learning objective. The student should
1. Acquire basic life support skills, including the diagnosis and treatment of shock and the related basic procedural skills; and demonstrate the basic application of these principles in real or simulated patient care scenarios. 2. Demonstrate the capacity to differentiate and treat common acute problems. 3. Provide a comprehensive assessment of the undifferentiated patient. 4. Demonstrate proficiency in basic life support skills and cardiopulmonary resuscitation. 5. Recognize and initiate first aid for airway obstruction. 6. Recognize and be prepared to intervene for all causes of shock in any age group. 7. Be able to provide rapid stabilization with intravenous access and fluid/blood administration. 8. Understand the principles of cerebral resuscitation in brain illness and injury. 9. Demonstrate proficiency in the use of an automatic external defibrillator (AED). 10. Understand the principles of wound care. 11. Demonstrate basic wound care techniques. 12. Understand the principles of trauma management.
142 13. Demonstrate basic trauma management skills, such as initial assessment using the ABC approach and full spine immobilization. 14. Demonstrate mastery of basic procedural skills, such as airway management and venous access. 15. Recognize life-threatening illness or injury, and apply basic principles of stabilization to the early management of these entities. 16. Demonstrate the capacity to prioritize attention to those patients with more urgent conditions. 17. Describe the importance of the ED as a key link between the general population and the health care system. 18. Understand the role of the situations that are unique to emergency medicine: acute critical illness, intoxicated patients, media, out-of-hospital personnel, death notification for sudden unexpected death, disaster, language barriers, environmental illness/injury, injury prevention, assessment of complex and undifferentiated patients, ability to synthesize multiple and often incomplete sources of information to develop a management plan.
C. Hobgood et al. Manual, Dallas, TX, USA or equivalent manuals from the local community]. Performance indicators
1. 2. 3. 4.
Obtain basic cardiac life support (BCLS) certification. Demonstrate chin lift. Demonstrate bag–valve mask ventilation. Demonstrate the ability to clear an obstructed airway.
Curriculum year 2 Readings – Pathophysiology of respiratory failure Curriculum year 3 and/or 4 Readings – Introduction to anesthesia, Introduction to airway management. Performance indicators
Unique content areas for Emergency Medicine in Foundation Training Undifferentiated patient presentation. Time constrained decision making. Environmental illness and injury. Pre-hospital care. Transition point between community and hospital. Focused history and exam. Prioritized differential diagnoses. Lead role areas for Emergency Medicine in Foundation Training Acute illness. Acute injury. Disaster management. Death notification. Injury prevention. Medical decision making. Resource utilization. Toxicology.
1. 2. 3. 4. 5.
Demonstrate endotracheal intubation. List indications for intubation. List contraindications for intubation. Describe medications used for rapid sequence intubation. Describe the physiology of artificial ventilation.
Outcome measures At time of graduation, student will demonstrate the ability to: n manage an obstructed airway n manage a basic airway, and n perform an endotracheal intubation. This will be assessed by simulation on a mannequin or using direct observation of student skills by trained faculty during clinical situations.
Example curriculum format
Undergraduate Emergency Medicine Curriculum Content
To assist educators in crafting a curriculum that fits local needs, we have provided an example of a 4 years plan for a single learning objective. Educators may use this as a guide to construct individual-, national-, and institution-specific models for content delivery. This method is not intended to be prescriptive, but to provide a simple model for tailoring content to the unique educational models that exist throughout the world.
Skills curriculum
Learning objective # 5 Recognize and initiate first aid for airway obstruction. Curriculum year 1 Readings – Basic life support manuals, basic first aid manuals [e.g., American Heart Association Advanced Life Support
1. Clinical care skills 1.1. History and examination 1.2. Documentation 1.3. Decision making 1.4. Time management 1.5. Safe prescribing 1.6. Continuity of care 1.7. Therapeutic interventions 2. Communication skills 2.1. With colleagues 2.2. With patients and caregivers 2.3. Breaking bad news 2.4. Working with a team
143 3. Maintaining good medical practice – life long learning 3.1. Audit and clinical outcomes 3.2. Critical appraisal 3.3. Information management 4. Professional behaviour and probity – professional attributes 4.1. Career and professional development 5. Ethics and Legal 5.1. DNAR and advanced directives 5.2. The competent adult 5.3. Informed consent 6. Education – developing learning for others 6.1. Basic educational information delivery 6.2. Assessment and appraisal 6.3. Feedback 7. Maintaining good clinical care - risk management 7.1. Medico-legal issues 7.2. Confidentiality
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Speciality specific curriculum 16. 1. Generic Objectives for Resuscitation 1.1. Resuscitation – Airway 1.2. Cardiac Arrest/Peri-arrest 1.3. Shock – all varities (varieties?) 1.4. Coma 2. Anaesthetics and Pain Relief - Pain Management 2.1. Local anesthetic techniques 2.2. Safe conscious sedation 3. Wound Management 3.1. Basic wound debridement and closure 3.2. Identification and treatment of infected wounds 4. Generic Objectives for Trauma 4.1. Major Trauma 4.2. Head Injury 4.3. Chest Trauma 4.4. Abdominal Trauma 4.5. Spinal Injury 4.6. Maxillo-facial Trauma 4.7. Burns 4.8. Orthopedic Trauma 5. Generic Objectives for Musculoskeletal Conditions 5.1. Upper limb disorders 5.2. Lower limb and pelvis disorders 5.3. Spine and spinal cord conditions 6. Vascular Emergencies 6.1. Arterial limb threat 6.2. Venous – Deep Venous Thrombosis (DVT) 7. Abdominal Conditions 7.1. Undifferentiated abdominal pain 7.2. Haematemesis/malena 7.3. Anal pain and rectal bleeding 7.4. Diverticulitis 7.5. Abdominal aortic aneurysm 8. Urology 8.1. Acute urinary retention or bladder obstruction 8.2. Nephrolithiasis and colic 9. Sexually Transmitted Diseases 9.1. Identification and initial treatment for endemic diseases 10. Eye Problems 10.1. Acute conjunctivitis - bacterial and viral
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10.2. Acute vision loss 10.3. Acute eye trauma including globe rupture Ear, nose and throat (ENT) Conditions 11.1. Epistaxis 11.2. Infections of the head and neck Dental Emergencies 12.1. Dental abscess 12.2. Dental fracture Gynecology 13.1. Pelvic pain 13.2. Dysfunctional uterine bleeding Obstetrics 14.1. Ectopic pregnancy 14.1. Uncomplicated emergency vaginal delivery Cardiology 15.1. Basic electrocardiographic analysis 15.2. Recognition and initial treatment of acute myocardial infarction 15.3. Recognition and initial treatment of life threatening arrhythmia Respiratory Medicine 16.1. Airway obstruction 16.2. Respiratory failure 16.3. Asthma and restrictive airway disease 16.4. Acute pneumothorax 16.5. Pulmonary embolism Neurological Emergencies 17.1. Acute stroke 17.2. Spinal cord lesions 17.3. Peripheral neuropathies 17.4. Acute mental status change 17.5. Migraine 17.6. Meningitis 17.7. Vertigo Hepatic Disorders 18.1. Acute hepatitis 18.2. Liver failure 18.3. Acute cholecystitis and cholangitis Toxicology 19.1. Treatment of acute ingestions 19.2. Identification of basic toxidromes Acid Base and Ventilatory Disorders 20.1. Identification of acid base disorders 20.2. Initial management of the mechanically ventilated patient Fluid and Electrolytes 21.1. Basic principles of fluid administration 21.2. Dehydration 21.3. Hyperkalemia 21.4. Hyponatremia Renal Disease 22.1. Acute renal failure Diabetes and Endocrinology 23.1. Disorders of glucose metabolism 23.2. Thyroid disorders Haematology 24.1. Anaemia 24.2. Disorders of red cell function 24.3. Disorders of clotting Infectious Diseases and Sepsis 25.1. Endemic infectious diseases 25.2. Sepsis
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C. Hobgood et al. 25.3. Common infectious diseases or conditions (e.g. pneumonia) 25.4. Cellulitis and gangrene Dermatology 26.1. Blistering and exfoliative diseases 26.2. Differential diagnosis of rash 26.3. Parasitic conditions and infestations Rheumatology and Immunology 27.1. Crystal arthropathy 27.2. Arthritis 27.3. Immune disorders 27.4. Anaphylaxis Child Protection and Children in Special Circumstances 28.1. Child abuse signs and symptoms 28.2. Legal rights of parents to refuse care Neonatology 29.1. Neonatal resuscitation 29.2. Hyperbilirubinemia 29.3. Disorders of feeding 29.4. Neonatal fever Environmental Emergencies 30.1. Hyperthermia 30.2. Hypothermia and frostbite 30.3. Envenomation and environmental toxin exposure Oncology 31.1. Acute leukaemia 31.2. Neutropenia and neutropenic fever 31.3. Solid tumors 31.4. Complications of chemotherapeutic agents Pediatrics 32.1. Basic management of pediatric airway 32.2. Basic pediatric resuscitation 32.3. Common infectious diseases of childhood 32.4. Fever in the first 6 months of life 32.5. Common injury patterns for normal children Psychiatry 33.1. Acute psychosis 33.2. Mood disorders 33.3. Personality disorders 33.4. Acute suicidal and homicidal ideation 33.5. Substance abuse Major Incident Management 34.1. Concepts and application of triage
34.2. Field to hospital communication and chain of command 35. Legal Aspects of Emergency Medicine 35.1. Refusal of care 35.2. Informed consent 35.3. Malpractice 36. Research 36.1. Formulating a research question 36.2. Review of the medical literature 36.3. Basic research design 36.4. Basic preparation of manuscripts and written publications 37. Management 37.1. Leading teams and giving orders 37.2. Basic concepts of debriefing and giving feedback 37.3. Time flow management Further reading 1. The Foundation Programme Committee of the Academy of Medical Royal Colleges. Curriculum for the Foundation Years in Post Graduate Education and Training. Academy of Medical Royal Colleges. Available at: